rehabilitation

The core, this is the area of the body that everyone wants stronger and more tone. For it being an area of the body that is so heaviy sought after, it is often the most misunderstood and underutilized area of the body. How can that be possible when there are so many people walking around with 6-packs and 8-packs? Well would you believe me if I said having great looking abs doesn’t necessarily mean you have a strong core? Probably not. Well it’s true, you can have great looking abdominal muscles yet still lack sufficient strength in your core let alone functional strength.

The Core

Well for starters let’s define what the core is. Essentially the core would be considered any muscle/muscle group that shares a connection to the pelvis, ribcage, and spine. This also would include muscles that directly affect the length/tension relationship of these muscles. These muscles would include :

Because so many muscles contribute to the cores general make up this would suggest that the core has many functions, some of which that we take for granted when training them.

Nothing can happen without the core. Whether it is sitting, walking, or kicking a ball, the core does it all. If we break down what the core does at its most basic levels the cores abilities can be split into two categories, static and dynamic.

Static Core Strength

Static core strength at its most simplified could be considered as stabilization. This is your bodies ability to maintain the position of the pelvis, spine, and ribcage while outside forces act upon the body, such as gravity. This would suggest that your static core strength would require more endurance than power. Static core strength is also necessary in other scenarios that suddently shift our bodies momentum/equilibrium; like getting bumped into when walking, falling down, maintaing our body position as a car turns or stops, or shooting a gun. There are also intrinsic factors that affect stabilization of the core that are less thought about than its extrinsic partners. Examples of less thought of uses of static core strength include:

Breathing

Coughing/sneezing

Bladder control

The inner ear/ eye tracking/ balance

Dynamic Core Strength

Dynamic Core Strength is a combinatino of the stabilization of static core strength and motions at the back and hips that occur in all three planes of motion. What makes these motions so complicated is that the body must maintain a certain level of rigidity, absorb resistance fluidly, react to changes in speed, and apply all of the above during motions that occur in all planes. Because of this it takes a high level of coordination between bones, joints, ligaments, muscles, tendons, and nerves to create movement that is both efficient and doesn’t harm any of the related structures as well as the extremities that attribute to the motions occuring. Examples of motions that require dynamic strength include:

Walking,jogging, running

Jumping

Kicking soccer ball

Throwing a baseball/softball

Swimming

Skating

All of these motions involve the spine flexing, extending, rotating, and bending side to side, sometimes all at the same time. Other aspects of dynamic strength that are often forgotten about are body position/orientation,surface that is being trained on/competed on, and types of shoes during training/competition. This takes understanding and implenting how to train dynamic core strength to a different level.

Take walking/jogging/running for example, doing these activies on a flat surface activates the core in a very specific way. The total work the body must output stays relative to the speed in which you are going. Add a hill with an upward slope and your core is being activated in a completely different manner. There must be an increase in the amount of total work performed by the joints or specifically certain joints like the hips (home of the core). While work increases in all joints it takes more effort at the hips to create the power necessary to climb the hill.

Surface trained on also has a dramatic effect to the core. This is because of a concept called ground reaction force. Ground reaction force (GRF) is the force exerted by the ground on a body in contact with it. So just as you exert force downward into the ground it will exert force back into you. This makes activities very different once you go from concrete, hardwood, grass ( well maintained or poorly kept), turf ( long, medium, shag), sand, or soft surfaces ( foam pit, trampoline, or mats). Your core must react based upon the demands you have placed upon it, thus training using different surfaces must happen in such a way that it challenges the core, without being too demanding, but is also functional to where the core will be used in competition.

To further complicate training you must finaly take into account the type of shoe a person is training in/competes in. There are many examples such as:

baseball/softball cleats

soccer cleats

track spikes

football cleats

ice skates

bare foot

basketball shoes

cross trainers

The best example of this is any version of the minimalist shoe. If you are wondering what a minimalizt shoe is the nike free is a perfect example of this type of shoe. Take a look at it this .gif of an athlete training in the nike free.

Look at how the shoe alters the ground reaction force of trying to decellerate and accelerate again. The amount of time/distance it takes to slow down has increased which causes the core to have to increase the amount of output to slow the body down as well as speed it back up. This in turn can cause an injury if the core muscles are not strong enough to create such forces or it can teach the body dysfunction by utilizing the wrong structures to slow down the body like joints, tendons, and ligaments versus muscle groups.

Activating the Core

If I were to ask someone how to work their core I would wager it would like one of these examples:

While there is nothing wrong with any of these exercises because they do activate the core when we look at all the things the core is capable of doing are we really unlocking its true potential? Not by a long shot. When you look at many of the traditional positions that people use to earn their 6-pack they all include hip flexion or lumbar flexion and return right back to neutral, one part of the what makes up the core is locked in place either the ribcage or the pelvis, and lastly they are not in a gravity dependent position. These exercieses will get you good looking abs but will not increase your function or performance by any means. The reason for this is mostly because, as we previously discussed, the core is a unit compromised of three parts that must be capable of moving independetly and interdependtly of one another WHILE working with the extremities to create function. To unlock the true potential of the core you must take into account several key factors:

Eye tracking

While you are reading this stand up, take one of your hands ad press your figers into your abs, now turn your head to the opposite direction of your hand. Stay standing, keep your fingers on your abs and close your eyes and turn your head again in the opposite direction of your hand. Try that same thing on single leg or in a split stance position. Chances are if your abdominal musces are working properly by doing something very simple like turning your head will cause them to activate. This is your bodies natural response to preparing itself for being put off balance. It is also a natural reaction for your body to stabilize so it may reach in the direction that you are looking. This is critical function of your core in order to protect your organs, your spine, and adjacent structures.

This is one of the differences between running on a treadmill or running outside. Your body has to locate where it is going to be in space and time and adapt to it. When you are staying in place and looking straight ahead or looking at a tv your body loses the ability to gain these adaptations. The second part of using eye tracking with core exercises is reaching to grab or catch something. The core becomes a stronger integrated system when relying on the feedback from your feet, knees, and hips while looking in another direction to reach or catch an object. It gives the brain an ability to activate the core for better protection from the hands all the way down to the feet which otherwise couldnt be accomplished with norma means of training the core. A example of this would be medball throws off of a trampoline, catching a medball over your shoulder, taking away eye tracking and performing certain exercises with your eyes closed. Next time when planning a core workout take into account how beneficial having to look and reach or catch and closing your eyes can be to improving your core strength.

Breathing

Breathing isn’t only a function that is necessary for us to sustain life but also helps to maintain function throughout daily life. When we breathe improperly it creates tension in the neck, causes ribs to be out of alignment, and can lead to seriuos back injuries. When you breathe correctly you allow your body to be able to lift heavier loads, increase endurance, and decrease chances of injury. Reading this all sounds a bit much because its just breathing right? WRONG! By utilizing the proper muscles to breathe you are helping to capture the lightning in the bottle that is the core.

The diaphragm helps to lift ad expand the ribcage causing the appropiate amount of tension thorughout the core

When people breathe using the wrong muscles it causes restrictions that can lead to upper cross syndrome, restrict cervical spine mobility, thoracic spine mobility, and lumbar spine mobility, and decreases effectiveness of respiration

By breathing with your diaphragm you will gain straonger oblique and transversus muscles rather than the usual dominant rectus abdominal muscles

Here is a short video of how to start learning how to use your diaphragm https://m.youtube.com/watch?v=2Jzc5VUAmw0 . Learning how to breathe properly is often taken for granted when seeking a stronger core so when you have a few minutes in your workout try it out and see what you think.

Arm/Leg Position

The body is designed to move, plain ad simple. This means from head to to being able to integrate motions like bending over to pick something up, reaching to grab something high up, doing a back hand spring , or swinging a softball/baseball bat. When performing all of these activities the extremeties come into play. The moment your arms or legs begin to reach in any general direction tension is placed upon the core muscles to prepare the pelvis, spine, and ribs for movement. These types of motions are often where performance is lost or injuries occur. Core muscles like any muscles need the ability to both lengthen and shorten. By performing activities that only shorten the core power, performance, and functionality is lost or limited.

Say for instance you train the core in such a way that you are doing planks,crunches, v-ups, or even using battle ropes. Now compare those actions to anything athletic; a basketball euro-step, a softball/baseball swing, a back hand spring, kicking a soccer ball, or throwing a football. The difference between the exercise and the activities mentioned are the fact that the hips/groin, the glutes, the abdominal muscles, and the cervical,thoracic, and lumbar spine are being BOTH lengthened and shortened. This is where implementing something simple like reaching ( above head, across the body, down below the waist, or to the side) and leg positions (split stance, staggered leg stance, lunge stance, close leg stance, or single leg) play a vital role in changing your core workout from trying to get “pretty” abs to making real functional gains

Don’t Forget What’s Behind You

We spend so much time focusing on what is in front of us we often neglect what’s behind us. Strengthening these muscles appropriately is a game changer for anyone. The reason being, most posterior chain muscles; attach to mulitple segments of vertebrae, attach to the upper or lower extremities, work in tandem with your abdominal muscles, and support/stabilize the spine . Without proper activation of these muscles overall function is loss to the dominating anterior core muscles.

Lattismus Dorsi – This muscle is a unique muscle. It is the broadest muscles of the back that has joint actions for both the arm and the trunk. What also makes this muscle unique is the fact that the fascia of the lats is shared with the hamstrings by way of a structure called the sacrotuberous ligament. So by having weak or tight lats it can cause tightness in the hamstrings on the same side or even decrease function in the opposite side of your gluteus maximus.

Erector Spinae- Is a group of three muscles that runs from the base of your skull all the way down to your pelvis. This group of muscles assists with back extension and side bending at all levels of the spine. This group is often in poor balance with one another because the lower section of this muscle gets overworked leaving the middle and upper sections weak. This imbalance can cause the pelvis to tilt, excessive curvature of the lower back(lordosis), excessive curvature of the upper back (kyphosis), and injuries to the discs and shoulder impingements or strains. Working on appropriate posture and being mindful of movements throughout the entire back can help facilitate balance throughout this muscle group.

Rhomboids – The rhomboids are a group of muscles that attach to the spine and the scapula. They help keep the scapula pressed against the ribcage, pull the scapula downward, and help pull the scapulas back to maintain posture.When these muscles are underactive it can cause your scapula to move inappropriately wreaking havic on the shoulder. They can also lead to poor posture that can lead to injuries of the neck and low back. To help facilitate the use of the muscles performing actions that involve pulling rather than pushing this will help keep these muscles strong.

Qudratus Lumborum – The quadratus lumborum, like most back muscles, attaches to the spine, ribs, and pelvis. Its job is to assist in side bending, rotation, and affixes the 12 rib during breathing. Whats unique about this muscles is because of its location when it is underactive or overactive it can throw off its neighbors (the diaphragm and the psoas or hip flexor muscles) very easily. Quadratus Lumborum dysfunction can affect breathing and interrupt the mobility of the hips. When trying to develop these muscles incorporate side bending motions at the back and moving your pelvis side to side into your routine.

The Glutes- What is there to say about the all of the msuscles that are housed within the glute complex? EVERYTHING! Your glutes affect your hip flexors which attach to your spine, they attach to your pelvis which your abdominal muscles are attached to, they attach to your femur which is part of the knee, and part of it attaches to your pelvic floor which controls the bladder and more.The glutes affect so many things directly or indirectly that if they are weak performance will decrease and injury could occur in any segment of the body. It is important to implement motions that incorporate hip extension, hip internal rotation, and hip external rotation when looking to maintain a strong core.

Multifidus – This muscle or groups of muscles are little powerhouses. I say this because these muscles are very small yet have a great impact on your spines health. These muscles contribute to the fine motor control of your spine, assist in sidebending, extension, and rotation. Weakness in this muscle group is largely associated with low back pain. This is because of how much of a role this muscle plays in the stability of your spine. Before you attempt to reach for an object a healtht multifidus will activate to protect the spine. If this muscle group is weak it will not activate appropriately or it will fatigue quickly and the wrong muscles that do not provide small stability will take control and throw off how the spine functions. To work this muscle it requires very fine control.

Step 1. Lay on your stomach with a pillow underneath your hips OR on your side so that your spine is in neutral.

Step 2. Take your finger and place it a few fingertip widths away from the middle of your spine right at the level of your waistline

Step 3. While keeping your finger pressure where it is, try to flex the muscle underneath it just enough to cause your finger to raise slightly. That is your multifidus. If your fingers get pushed away significantly you are activating the wrong muscle.

Step 4. While you are doing this activation try to maintain a normal breathing rate.

This muscle group can prove to be very difficult to activate because it is often weak in most people. Once you have tapped into the ability to activate this muscle and give it some endurance your back will thank you many times over.

The Pelvic Floor Matters

The Pelvic floor muscles are the layer of muscles that support the pelvic organs and span the bottom of the pelvis. The pelvic organs are the bladder and bowel in men, and bladder, bowel and uterus in women. These muscles stretch like a firm thick muscular trampoline from the tailbone (coccyx) to the pubic bone (front to back) and side to side. The purpose of these muscles is to :

Provide support to the organs that lie on it.

Give us conscious control over the bladder and bowel until it is convenient.

Important for sexual function in both men and women.

Provide support for the baby during pregnancy and assist in the birthing process.

Work with the abdominal and back muscles to stabilize and support the spine.

When we look at the core its necessary to take into account everything that it encompasses. It is only to your detriment to only work some parts instead of the whole. Whether you workout to be healthy or to be elite none of the core’s components can be ignored because it will lead to dysfunction and ultimately a breakdown in the system. Next time you train incorporate a new component each time and see if it makes an impact in one way or another.

Growing up as an athlete in the United States it was normal that an Athletic Trainer covered my highschool’s practices and games, that water and Gatorade was always available whenever a team needed it, and rehabilitation and therapy ,when needed, an athletic trainer was available. It was not until recently traveling to another country did I realize that these simplistic “norms” are taken for granted.

Spending a month in Sicily I was curious as to how healthcare, rehabilitation of injuries mostly, is different in the United States when compared to Italy. I was fortunate enough to take a tour and spend a couple hours at a physical therapy clinic in a town outside of Palermo. To my surprise, this clinic was nothing as I had expected it to be. Braces and splints were not distributed to athletes due to budget constraints, a doctor only visited once a month, oils and natural product therapy is seen as more beneficial compared to ultrasound and electrical stimulation, and what shocked me the most was the amount of equipment available for rehabilitation. A thera-band section with precut bands ready for use, a treadmill, and a couple of free weights was all that was available to use to these patients.

When I asked about the limited equipment, the physical therapist informed me that most patients did not want to use equipment, but would rather perform exercises on their own. I was shell shocked when I heard that these patients perform their own physical therapy without any guidance. In Sicily everyone is active so getting back into the swing of things is easily done.

It should not have taken a trip to another country to realize how grateful we as healthcare professionals should be to have access to such beneficial equipment, doctors who understand and trust us, and most importantly patients who understand what we do.

If you have been in a physical therapy clinic, fitness center, or an athletic training facility in the past 5 years you have heard the word functional. It is often used to describe strength training, cardiovascular training, and rehabilitation exercises. Because the term functional has such a wide variety of applications, more often than not it is overused in terminology and underutilized in practice. With that being said, what is functional, how do we as healthcare professionals and coaches properly use this term, and how do we successfully apply it?

What is functional?

Webster defines functional as:

Designed to have a practical use

Affecting the way a part of your body works

Working properly

Webster does a great job of putting it succinctly. When all three portions of the word are combined and placed in front of the word exercise, the phrase functional exercise could be interpreted as performing a physical activity, designed with a practical use, to affect the way a part or parts of your body works to make yourself stronger and healthier. Or in the case of the phrase functional movement, the act of moving your body or a part of your body, designed with practical use, to affect the way a part or parts of your body works to ensure it is working properly. Regardless of how these definitions are spun together, the result will be the same. Functional is a movement or an exercise that is designed in such a way that is specific to how the body works, how the client/patient wants it work, and combined it will make sure their body is working properly. Now that we have gotten that out of the way, let’s take a look at these movements and exercises that we might consider to be functional.

Functional movement patterns and exercises

As I researched different topics, articles, blogs, and pod-casts regarding functional movement I found there was more opinion out there than fact. In spite of this there seemed to be a general consensus about a handful of movements or variations of the same movement that most individuals considered to be functional:

The Squat

The Lunge

The Hip Hinge

The Dead Lift

While I agree with the above being “functional movement patterns” do I consider them fully functional, no. I’m sure many of you who are looking at your computer screens just turned up your nose at that statement as it goes against many of the things we have been taught. I know it sounds crazy, but go with me for a moment as I explain. I made this statement for three reasons:

These movements do not become functional until both an upper extremity motion accompanies them and the proper foot placement is addressed

These movements are all sagittal plane dominant

These movements lack specificity

Because of these three reasons I consider these movements to be great foundations of function rather than true functional movements patterns as they allow a solid base to build from, yet lack the specificity to be considered fully functional

The What’s, the How’s, and the Why’s

The What’s

Let’s delve a little deeper into the “the what’s” we are dealing with first. Each of these foundations of function deserve a look into their benefits and pitfalls. First, it is very important that we look at the squat, the deadlift, the hip hinge, and the lunge from a different perspective. All of these movement patterns can be viewed as transitional movements, this is primarily because they are a way to “load the spring” in respect to the movement they precede. So let’s take a brief look at the four foundations of movement:

The Squat

The squat is such a pillar in the foundation of function because it isn’t possible to go through a day without squatting, whether its picking up your groceries or sitting down. Breaking down the squat can reveal a series of dysfunctions ranging from restrictions in the foot and ankle joints all the way up the kinetic chain to the cervical spine. As a transitional movement pattern we see the squat often preceding the movements of the lunge or the jump. For example, in the pictures seen above, in order to perform a defensive slide one must squat and transition to a single leg reach into a lateral or diagonal lunge. In the picture on the right hand side, in preparation to jump one must transition from a squat with cervical extension and a posterior arm reach into a jump. In both instances of the defensive slide and the jump, barring it is a pure vertical jump, there is a tri-planar aspect that occurs in relation to squatting where a true squat remains sagittal plane dominant.

The lunge

The lunge, especially in world of athletics, is a critically important fundamental movement pattern. It is the first step taken to drive to the basket, it is the action required to deliver a pitch, and in the case of the picture above it is the lunge that allows the tennis player to reach the ball. When we look at the traditional lunge it does a great job of showing the interdependence of the left side of the body to the right side of the body and reveals left side right side dysfunction when used as an assessment tool. The traditional lunge unfortunately is limited, regardless of it is performed laterally or diagonally. If we compare the right picture to any lunge you’ll notice how vastly different these lunges are from one another. As Serena attempts to backhand the tennis ball she has positioned her foot into external rotation, her thoracic spine is left rotated while er cervical spine is flexed and right rotted, and her upper extremities are reaching left lateral and inferior. Even if one were to lunge anteriorly, laterally, or diagonally the combination of the neutral spine and lack of tri-planar loading leaves much to be desired in the way of function in this instance of training or assessing a tennis player.

The Hip Hinge

Here we have the hip hinge, another great foundation of function known for its excellent ways of loading the hips by way of the posterior chain. It gives a great view of how mobile the hips are and how strong the glutes are. Put into practice we have Tiger Woods going through a golf swing motion. Notice how he must hip hinge in order to begin the motion of swinging his club. This hip hinge must evolve in order for him to forcefully drive his club into the ball. This force production requires rotation of his cervical and thoracic spine, an upper extremity reach that is superior and right lateral, and pelvic rotation driving his left femur into external rotation and his right femur into internal rotation. This significant “gapping” in utilizing the bodies full resources is where the hip hinge diverges from its ability to becoming a fully functional movement pattern.

The Dead Lift

The dead lift, the last of the foundations of function, is used to develop and assess the posterior chain primarily by way of the hamstring complex. Once again, a great tool to have in your bag of assessment and training techniques, but can fall short of true function. For example, when we look at the follow through of a baseball pitcher he must maintain cervical extension and left lateral rotation if he is a lefty, pelvis on femur internal rotation, right lateral thoracic rotation, and a left hand reach to the right inferiorly and posterior. This is so that the pitcher may decelerate the speed of his arm and upper body as well as recoil back to a ready position in order to react to the ball once it has or hasn’t been hit.

As we look at these four comparisons it is both intriguing and exciting to see how many avenues there are to reaching function. There is no, one answer to the same question. If we are to better serve our patients, athletes, and clients our approach should be individualized with a focus on how they move in a three dimensional world. In part two of this series the “how’s and why’s” of the “what’s” that was previously discussed will be addressed. Thank you for taking time out of your busy schedule to read this article, check in later this week for part two of “Is Your Functional Functioning”.